Care in Maryland's 261 nursing homes has declined even as elderly residents have grown frailer and sicker, according to a report to the General Assembly that finds state laws neither support early intervention at troubled facilities nor encourage improvement and innovation at good ones.

The 40-page document, which will be presented to legislators this week as they open their 2000 session, suggests immediate changes in nursing home staffing and pay, worker training, oversight, fines and consumer rights. Two recommendations alone could cost the state more than $48 million annually--a price tag that advocates acknowledge will be tough to sell even in these flush budget times.

Yet, as Maryland's secretary of aging, Sue Fryer Ward, wrote in a cover letter to Gov. Parris N. Glendening (D): "The quality of care in Maryland nursing homes is in need of immediate government attention. Substantial investment of both financial and human resources over the long term will be required to realize changes needed today."

The report is the result of six months of hearings and study by a task force that included Ward and eight legislators. It cites a sharp rise since 1998 in the number of substandard facilities. Complaints alleging actual harm to residents also nearly doubled in that period, to 1,013. In 1998, more than 26,000 men and women in Maryland received care in nursing homes, most of those for-profit facilities.

One remedy for poor care would be to require that every facility provide at least four hours of direct nursing care daily per resident, compared with the current state minimum of two hours. This change would cost Maryland, through its Medicaid program, more than $35 million a year.

But mandating greater staffing would not be feasible unless other issues were tackled. A Carroll County nursing home administrator who spoke before the task force recounted hiring 159 employees and losing all but 26 at the end of 18 months--often to far less back-wrenching jobs at Wal-Mart and McDonald's.

"Nursing assistants, who provide most of the care in the homes, are in a position with little mobility, limited opportunity, and poor pay," the report notes. "The result is large turnover in these positions and continued staff shortages."

The task force recommends that nurses aides receive a $2-an-hour, Medicaid-funded increase regardless of their current wage. It also seeks more training and mentoring opportunities, scholarships and internships to encourage young people to enter the field, and far greater attention by nursing homes on ways to recruit and retain staff.

"Without an attitude change, without a real appreciation of what direct caregivers need emotionally, bigger pay will just meet Wal-Mart," Ward said in an interview. "I think it's broader than pay."

She expressed satisfaction in the task force's final product, that "no one wanted to hide anything, and that included the industry." Ward is realistic about the task force's proposals, however, predicting that key changes would have to be phased in.

"The legislature will have to buy into it wholly, and some legislators see dollar signs only," she said.

The General Assembly created the task force last year as fairly tough legislation was, in the view of reformers, being gutted because of industry lobbying. The pressure was on, though, here and nationally.

A "Dignity Campaign" by the Service Employees International Union underscored the severe understaffing in some homes, as well as the rising incidence of worker injury. And embarrassingly, the federal General Accounting Office singled out Maryland when it described how many facilities nationwide place residents at risk of injury or death. Maryland, it said, spent far less investigating complaints than other states and tended to minimize the severity of the complaints.

Maryland's long-term care has drawn repeated attention since late 1997 because of shortcomings in state and local programs that monitor conditions or check for criminal backgrounds among workers. Tougher federal regulation intensified the scrutiny of the facilities even as many began to cut staff in response to decreased reimbursement rates.

"I think we did an excellent job at peeling back the onion and trying to understand all the issues," said task force member Del. Peter A. Hammen (D-Baltimore), who nonetheless is skeptical that his legislative colleagues will fully embrace the most expensive points. "A lot of them are going to have problems with that."

A vice president for the Health Facilities Association of Maryland reacted positively to the report. "Stabilizing the work force of direct caregivers is one of the most important things that can be done," said Mark Woodard, whose organization represents 154 nursing homes containing more than 20,000 of the state's 31,500 beds.

Not that Woodard is willing to agree to all of the findings. "Although there's a perception that quality of care has diminished, we don't necessarily believe that perception is completely true," he said Friday.

The union plans to keep pressure on lawmakers by bringing 150 nursing home workers to Annapolis next week to push for the pay and staffing changes. With a state surplus of $925 million and $4.4 billion expected over the next 20 years from the national tobacco settlement, the opportunity is there "and it may not come again," said Robert Moore, president of the state chapter of the service employees union.

But others are intent on not letting the voices of families and elderly residents themselves go unheard. And while they applaud the task force's push for a strong family council in every nursing home, for display of staffing levels in a facility and for significant expansion of the ombudsman program that often is a family's most personal contact in times of trouble, some of them are less upbeat about the task force's finished product.

Jerome Erbacher, president of the family council at HCR-Manor Care Chevy Chase, testified before the task force at a forum in Gaithersburg and views its staffing suggestions as far short of what's needed.

"What nursing homes have done is staff down to the lowest common denominator," he said last week. "They say, 'What would you rather have, quality or bodies?' I want both."

But if the report can truly be a first step, he's willing to take it. "I really think we have reached a point in time, because of our demographics, that [long-term care] is no longer a service. It's a public-utility good. And too many people need it, and it's not there."